Lessons learned from COVID-19, H1N1, and routine vaccine pharmacovigilance in the United States: a path to a more robust vaccine safety program

INTRODUCTION

Vaccine pharmacovigilance is an essential component of vaccine safety programs. Vaccine pharmacovigilance refers to detecting uncommon adverse events following immunization (AEFI), determining whether they are due to the vaccine or are only a coincidence, and, for those AEFI considered related to vaccination, characterizing them further. When AEFI are due to vaccination, it is important to characterize the attributable risk and ascertain the biological mechanism causing the adverse reaction to inform efforts to prevent or mitigate the risk. A robust post-authorization safety system is necessary for vaccine decision-making, clinical recommendations, vaccine compensation, and vaccine communication and confidence.

AREAS COVERED

This paper describes the key characteristics of vaccine pharmacovigilance programs, reviews US vaccine pharmacovigilance for routine vaccination programs, COVID-19, and H1N1, and makes recommendations for improving future vaccine safety systems.

EXPERT OPINION

The key characteristics of vaccine pharmacovigilance programs include passive surveillance, active surveillance, clinical investigation and special studies, and causality assessment. Recent examples illustrate the strengths of US pharmacovigilance systems, including systems for passive and active surveillance, as well as areas for improvement, including study of pathogenesis, consistent funding, and leadership. We make recommendations that would, if implemented, further strengthen the vaccine safety system for future routine and pandemic immunizations.

The Case of the Disappearing Thank Yous

This JAMA Forum discusses declining time and space for appreciation of what has been accomplished in clinical medicine and health policy.

The Opioid Settlements-Will the First Steps Be in the Right Direction?

This JAMA Forum discusses ways the opioid settlement funds could be used to save lives today and in the future, aspects of the decisions surrounding funding, and the importance of measuring progress.

Judicial interference with mifepristone

In the days since Texas federal judge Matthew J. Kacsmaryk invalidated the approval by the US Food and Drug Administration (FDA) of mifepristone, a medication used to terminate pregnancy, a shock wave of concern has swept through many people, organizations, and companies that work closely with the agency. The strong opposition reflects the high stakes not only for pregnant persons and for the FDA, but also for the scientific process of drug development and public access to safe and effective medications. Twists and turns in the case are already happening. A federal appeals court stayed the full suspension of mifepristone, but permitted multiple restrictions on its availability. Then the Supreme Court, which recently overturned the constitutional right to abortion, kept the status quo in place for a few days while considering the government's appeal. The results of the legal battle will be enormously consequential for reproductive health care-and far beyond, for innovation, science, and health.

Efforts to Modernize Public Health-An Unexpected Bright Spot

This JAMA Forum discusses innovative efforts in various states to improve public health by providing more funding and programs with input and support for reform from local residents, businesses, and community organizations.

Analysis of Ingredients of Supplements in the National Institutes of Health Supplement Database Marketed as Containing a Novel Alternative to Anabolic Steroids

This case series analyzes whether supplements categorized as containing novel ingredients in the National Institutes of Health Dietary Supplement Label Database are accurately labeled.

Performance and Priorities: A Cross-sectional Study of Local Health Department Approaches to Essential Public Health Services

OBJECTIVES

Despite a push for increased local public health capacity, no clear baseline for performance of local health departments (LHDs) exists. The objectives of this study were to quantify the self-reported performance of LHDs on the 10 Essential Public Health Services (EPHSs) and describe the relationships between performance and characteristics of LHDs.

METHODS

We used data on 2000 LHDs from the 2013 National Profile of Local Health Departments survey to develop principal components analysis-based scores to evaluate each LHD on the performance of EPHSs. Scores ranged from 0 to 100. LHDs that performed no activities within an EPHS had a score of 0, and LHDs that performed all activities within an EPHS had a score of 100. We explored the relationships between EPHS scores and LHD characteristics by using multivariate linear regression and cluster analysis.

RESULTS

Performance scores varied greatly by LHDs and EPHSs; however, LHDs typically scored <50, indicating that they performed fewer than half of the activities evaluated. LHDs that served larger populations (vs smaller populations) and LHDs that had higher per-capita funding (vs lower per-capita funding) had higher EPHS scores. We identified 6 EPHS performance score-based LHD clusters, which suggests similarities in which EPHSs LHDs focused on.

CONCLUSIONS

Our results suggest weaknesses in many LHDs' fulfillment of the EPHSs, particularly in low-population and low-funding settings. LHDs should be given the resources to increase capacity and ensure the EPHSs are met in communities.

Assessment of the FDA Risk Evaluation and Mitigation Strategy for Transmucosal Immediate-Release Fentanyl Products

IMPORTANCE

Transmucosal immediate-release fentanyls (TIRFs), indicated solely for breakthrough cancer pain in opioid-tolerant patients, are subject to a US Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategy (REMS) to prevent them from being prescribed inappropriately.

OBJECTIVES

To evaluate knowledge assessments of pharmacists, prescribers, and patients regarding appropriate TIRF use; to describe sponsor assessments, based on claims data, of whether the REMS program was meeting its goals; and to characterize how the FDA responded to REMS assessments.

DESIGN, SETTING, AND PARTICIPANTS

Qualitative analysis of 4877 pages of FDA documents obtained through a Freedom of Information Act request, including 6 annual REMS assessment reports (2012-2017), FDA evaluations of these reports, and FDA-sponsor correspondence about safety issues.

EXPOSURE

A REMS program to reduce the risk of adverse outcomes, including misuse, abuse, addiction, and overdose, arising from use of TIRFs.

MAIN OUTCOMES AND MEASURES

(1) Knowledge assessments of pharmacists, prescribers, and patients; (2) survey and claims-based prescribing assessments; (3) FDA and TIRF sponsor communications; (4) modifications to the REMS program; and (5) disenrollment of noncompliant prescribers.

RESULTS

Twelve months after initiation of the program, 24 of 302 pharmacists (7.9%), 35 of 302 prescribers (11.6%), and 5 of 192 patients (2.6%) incorrectly reported that TIRFs can be prescribed to opioid-nontolerant patients, with similar levels of misunderstanding maintained in the subsequent reports. At 60 months, product-specific analyses of claims data indicated that between 34.6% and 55.4% of patients prescribed TIRFs were opioid-nontolerant. In the 48-month survey, 106 of 310 prescribers (34.2%) reported prescribing TIRFs for opioid-tolerant patients with chronic, noncancer pain; at 60 months, 54 of 302 prescribers (18.4%) and 148 of 310 patients (47.7%) erroneously reported that TIRFs were FDA-approved for such use. Over the 60-month period examined, there were few substantive changes made to the REMS to address evidence of high rates of off-label TIRF use, and, although the REMS program had a noncompliance plan, there was no report of prescribers being disenrolled for inappropriate prescribing.

CONCLUSIONS AND RELEVANCE

In this review of FDA documents pertaining to the TIRF REMS, surveys of pharmacists, prescribers, and patients reflected generally high levels of knowledge regarding proper TIRF prescribing, yet some survey items as well as claims-based analyses indicated substantial rates of inappropriate TIRF use. Despite these findings, the FDA did not require substantive changes to the program.

Behavioral Health, Local Health Department Accreditation, and Public Health 3.0: Leveraging Opportunities for Collaboration

The rise of the opioid epidemic and the increasing rate of suicides have drawn attention to mental health and addiction and have highlighted the need for collaboration between public health and behavioral health. However, these 2 fields have had limited engagement with one another. The introduction of Public Health 3.0 and population-based financing models that promote prevention and value in health care have created opportunities and incentives for local health departments and behavioral health agencies and providers to work together. New undertakings include the creation of accountable care organizations, community health needs assessment requirements for all non-profit hospitals, local health department requirements to conduct community Health Assessments (CHA), and increasing numbers of public health departments that are pursing accreditation. We argue that by taking advantage of these opportunities and others, local health departments can play a vital role in addressing critical challenges in mental health and addiction facing their communities.

Sharing Overdose Data Across State Agencies to Inform Public Health Strategies: A Case Study

Data sharing and analysis are important components of coordinated and cost-effective public health strategies. However, legal and policy barriers have made data from different agencies difficult to share and analyze for policy development. To address a rise in overdose deaths, Maryland used an innovative and focused approach to bring together data on overdose decedents across multiple agencies. The effort was focused on developing discrete intervention points based on information yielded on decedents' lives, such as vulnerability upon release from incarceration. Key aspects of this approach included gubernatorial leadership, a unified commitment to data sharing across agencies with memoranda of understanding, and designation of a data management team. Preliminary results have yielded valuable insights and have helped inform policy. This process of navigating legal and privacy concerns in data sharing across multiple agencies may be applied to a variety of public health problems challenging health departments across the country.

Development of Maryland Local Overdose Fatality Review Teams: A Localized, Interdisciplinary Approach to Combat the Growing Problem of Drug Overdose Deaths

The Maryland Local Overdose Fatality Review Teams (LOFRTs) are multiagency, multidisciplinary teams that critically analyze individual cases of drug overdose in their jurisdictions to identify preventable risk factors and missed opportunities for intervention, and to make policy and programmatic recommendations to prevent future overdose deaths. Three Maryland LOFRTs were first piloted in early 2014, and became established in law in May of the same year. LOFRTs provide unique opportunities for enhanced interagency collaboration and locally driven prevention efforts. This study describes the process of establishing LOFRTs in Maryland. The experiences and information regarding LOFRTs may help counties in other states combat the growing problem of deaths by drug overdose.

Smoking behaviours and attitudes among male restaurant workers in Boston's Chinatown: a pilot study

OBJECTIVE

Asian American immigrants experience high rates of cigarette smoking. A community based survey was conducted to understand the smoking behaviours, knowledge, and attitudes of restaurant workers in Boston's Chinatown.

DESIGN

Cross sectional survey in Chinese of a convenience sample of 54 restaurant workers recruited through extensive outreach activities.

RESULTS

All 54 of the workers were male immigrants. 45 (83.3%) reported smoking cigarettes regularly, and the remaining nine were former smokers. 36 of the smokers (80.0%) started smoking before entering the USA. The workers were aware that cigarettes are addictive (98.1%), cause lung cancer (79.6%), and lead to heart disease (64.8%). However, a substantial number reported that smoking was relaxing (75.9%) and enhanced concentration (66.7%). Nearly half believed low tar and low nicotine cigarettes to be safer than standard brands. The vast majority of workers believed that smoking was not socially acceptable for women. Smokers reported they received information on quitting most commonly from friends (60%), newspapers (53.5%), and television (44.4%). The restaurant workers most often saw advertising against smoking in Chinese newspapers (63%).

CONCLUSION

Despite high rates of smoking, Chinese American restaurant workers were generally aware of the health risks and were interested in quitting. Community based research can set the stage for targeted public health efforts to reduce smoking in immigrant communities.

Kids first?

Nearly 20 years afer the licensure of a vaccine against the hepatitis B virus, an estimated 300,000 U.S. residents still become infected with the potentially fatal liver virus every year. One major reason for the persistence of hepatitis B is that few adolescents and adults whose sexual and drug-using behavior places them in danger of infection are able to obtain the vaccine. Public health authorities and legislators have spent hundreds of millions of dollars to vaccinate low-risk but politically popular babies, while largely ignoring high-risk older siblings, parents, aunts, and uncles. Now this strategy, chosen in part for political reasons, is unwittingly fueling anti-vaccine efforts. The United States' poor use of the hepatitis B vaccine will surely cast a shadow over efforts to prevent HIV, a disease with remarkably similar transmission patterns.

1996 congressional campaign priorities of the AMA: tackling tobacco or limiting malpractice awards?

OBJECTIVES

This study sought to determine whether the political action committee of the American Medical Association (AMA) contributed more to pro- or anti-tobacco members of Congress in the 1995/96 campaign and whether representatives' voting records on malpractice reform could explain the AMA's contribution patterns.

METHODS

Campaign contributions to House members were analyzed.

RESULTS

The AMA's political action committee contributed averages of $5382 to pro-tobacco representatives and $2103 to anti-tobacco representatives (P < .0005). This contribution pattern can be fully explained by representatives' votes to limit malpractice awards.

CONCLUSIONS

In seeking malpractice reform, the AMA contributed significantly more to pro-tobacco representatives, potentially undermining tobacco control legislation.